CMS Proposes New Medicare Physician Payment System (Source: US Oncology)

On April 27, the Centers for Medicare and Medicaid Services released much-anticipated proposed regulations that will govern implementation of the new Medicare physician payment system that replaces the sustainable growth rate (SGR) formula repealed by Congress last year.

The new system offers physicians two pathways for Medicare payment beginning in 2019: the Merit-Based Incentive Payment System (MIPS) or participation in an alternative payment model (APM).

Merit-Based Incentive Payment System (MIPS)
MIPS scores would be used to calculate a physician’s adjustment to their Medicare payments. In year 1, adjustments are calculated so that negative adjustments can be no more than 4%, and positive adjustments up to 4%, with additional bonuses for the highest performers.

CMS would begin measuring performance for doctors and other clinicians through MIPS in January 2017, with payments based on those measures beginning in 2019.

MIPS consolidates current reporting programs into four performance categories across which all physicians will be compared to one another:

  • Quality
    Accounts for 50% of total score in year 1. Physicians would choose six measures to report including one crosscutting measure and one outcome measure or another high quality measure.
  • Advancing Care Information
    Accounts for 25% of total score in year 1. Physicians would report measures of their choice that reflect how they use electronic health record (EHR) technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. This category would not require all-or-nothing EHR measurement or quarterly reporting.
  • Clinical Practice Improvement Activities
    Accounts for 15% of total score in year 1. Physicians would be rewarded for clinical practice improvement activities such as care coordination, beneficiary engagement, and patient safety. In addition, physicians would receive credit towards scores for participating in Alternative Payment Models such as the Oncology Care Model (OCM) one-sided risk arrangement.
  • Resource Use
    Accounts for 10% of total score in year 1. The score would be based on Medicare claims using more than 40 episode-specific measures to account for differences among specialties.

Advanced Alternative Payment Models
Physicians successfully participating in Advanced Alternative Payment Models would be exempt from MIPS payment adjustments and would qualify for a 5% Medicare incentive payment.

To qualify for incentive payments, physicians would need to receive enough of their payments (25% in years 1 and 2) or see enough of their patients through Advanced APMs (20% in years 1 and 2). The participation requirements would increase over time.

  • The Oncology Care Model Two-Sided Risk Arrangement (available in 2018) is included in the proposed rule’s list of qualified Advanced APMS.
  • Other Payer APMs, led by commercial payers or state Medicaid departments, can also help physicians meet the requirements to earn the payment incentives (starting in 2021).

The proposed rule also establishes the Physician-Focused Payment Technical Advisory Committee to review and assess additional physician-focused payment models suggested by stakeholders. CMS will evaluate Other Payer APMs on a case-by-case basis.

The US Oncology Network will continue to analyze the proposed rule and provide greater detail and explanation in the near future.

To view CMS Resources on the proposed rule, CLICK HERE
To view the CMS factsheet, CLICK HERE
To view the proposed rule, CLICK HERE

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